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A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the ball of a finger as the puncture site
- B. Uses the side of a fingertip as the puncture site
- C. Avoids using the fingers of her dominant hand as puncture sites.
- D. Avoids using the thumbs as puncture sites
Correct Answer: B
Rationale: The correct answer is B: Uses the side of a fingertip as the puncture site. This is because the side of the fingertip has fewer nerve endings compared to the center, making it less painful for blood glucose monitoring. Choice A is incorrect as using the ball of a finger can be more painful. Choices C and D are incorrect as there is no specific reason to avoid using the fingers of the dominant hand or thumbs as puncture sites. It is important to choose a less painful site for blood glucose monitoring to encourage the client to monitor regularly.
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A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
- A. Wear a mask when entering the client's room.
- B. Remove potted plants from the room.
- C. Allow the client to leave the room every 2 hr.
- D. Dedicate equipment and supplies for use with the client.
Correct Answer: D
Rationale: The correct answer is D: Dedicate equipment and supplies for use with the client. This is essential for preventing the spread of infection. By dedicating equipment to the client, the nurse reduces the risk of contaminating other clients. Choice A is incorrect because wearing a mask is not necessary for contact precautions unless respiratory droplets are a concern. Choice B is irrelevant to contact precautions. Choice C is incorrect as allowing the client to leave the room frequently can increase the risk of spreading infection.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and allows the client to share their reason for seeking care, which can provide valuable information for the nurse to understand the client's current health status and concerns. It also helps establish rapport and encourages the client to share their perspective.
Rationale for other choices:
B: Asking about all medical issues is too broad and may overwhelm the client, leading to a less focused discussion.
C: Asking if the client wants to talk about health concerns puts the onus on the client to bring up topics, which may hinder open communication.
D: While discussing feelings is important, it may not be the most immediate priority during admission and may not capture the primary reason for seeking care.
A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?
- A. Corticosteroids
- B. NSAIDs
- C. ACE inhibitors
- D. SSRIs
Correct Answer: A
Rationale: Corticosteroids can cause potassium loss through increased renal excretion, leading to hypokalemia.
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important as it allows the family to have closure, grieve, and say their goodbyes in a respectful and private manner. It also promotes a sense of dignity and respect for the deceased. Choice A is incorrect as it may delay the family's grieving process. Choice B is incorrect as postmortem care should be performed after the family has had a chance to view the body. Choice C may be helpful but is not as essential as allowing the family to view the body privately.